July 10, 2008

HEALTH HISTORY
Current health problems: CVA
Family Risk Factors
Habits: Drinking alcohol with friends and relatives and neighbors
Health Maintenance Practice: Whenever he felt untoward signs and
symptoms he just take a rest and take some medication
Medications: Catapres
Past health problems: hypertension
Surgical History: None
Accidents: None

PSYCHOSOCIAL Significance
Significant others: wife, children, >the presence of the SO helps the
relatives and friends and neighbors pt in overcoming problems

Coping mechanism: socialization with

family and friends
Religion: Jehovah’s witness
Primary Language: Ilocano and Tagalog
Primary source of health care: RHU and
NVPH
Financial resources related to illness:
their family income
Educational background: College
graduate
Occupation: self employed
General appearance: still weak in
appearance, no contraptions >oriented to time, date and place
Affect: normal affect >able to recall his past and
Orientation: well oriented present activities
Memory: Intact
Speech: audible

Non-verbal Behavior: smiling, nodding

 ELIMINATION Pathophysiological basis
Stool #: 1
Urine
Quantity per voiding: 200-250 ml >increased fluid intake
Pattern: 9-12x daily
Color: yellow
Clarity: Clear

REST AND ACTIVITY

Current activity level: sitting in bed >
Activities of daily living: eating,
brushing, chatting with family and
friends
Sleep: 6-8hrs per day
Body frame: endomorph
Muscle strength: right side
body>5/5
Left side
body>4/5
Muscle tone: R>normotonic
L>normotonic
Motor function
Fine: upper extremities>both
right and left can able to touch the
nose
Lower extremities >both
right and left can touch nurse
hands
Range of Motion
Legs: 5/5R-4/5L
Arms: 5/5R-4/5L
Pain relief measures: resting
Mobility/Use of assistive device:
None
 SAFE ENVIRONMENT Pathophysiological basis
Allergies Reaction
Medications: None
Food: None
Environment: None
Eyes vision
Glasses: None
Pupils: PERRLA Pupil equally round reactive to light
accomodation
Hearing: Appropriate >able to answer questions correctly
Skin Integrity >he has good skin integrity
Lession/scars: None
Surgical Incision wounds: None
Mucous membrane: moistened lips
Temperature: 36.9 degrees
Celsius(axilla)

OXYGEN
Activity tolerance: changing
position in bed without assistance,
Airway clearance: clear
Nose: no obstruction
Mouth: no obstruction
Respirations:
-RR 16 cpm
- Lung sound: clear upon
auscultation
Color of:
Nail beds: pinkish
Lips: pinkish
Capillary Refill: 1-2seconds
Peripheral pulses:
Location: radial
Rate: 63pbm
Blood pressure: 120/80 mmhg
O2 therapy: none
 NUTRITION

Hospital diet: DAT

Fluid intake: water and milk
IVF’s: none >his weight was still the same

Height:5’7”
Weight:75 kgs
IBW:
Tissue turgor: good
Ability to:
Chew: yes
Swallow: yes